Authors:
Nic Uren, Julia Judd, Ed Lindisfarne, Kirsten Elliott, Alex Aarvold

Hospital:
University Hospital Southampton

Introduction:
Gallows traction is used before the surgical reduction of dislocate. Despite requiring extended hospital stays, traction theoretically reduces soft tissue tension, allowing an easier surgical reduction and thus fewer complications including re-dislocation and avascular necrosis. This study aims to quantify the effectiveness of Gallows traction at altering the resting position of the hip.

Methods:
All infants less than 12kg treated with hip open reduction surgery undergo pre-operative gallows traction at our institution. Patients have a pre-traction radiograph, repeated pre-operatively in theatre with traction removed. The resting position of the hip before and after traction was compared in eighty consecutive patients using the IHDI classification system. The re-dislocation rate and the prevalence of clinically relevant AVN following our surgical protocol was calculated in a longer-term cohort (mean 8 years) of 100 patients.

Results:
Before traction, 49 hips were IHDI grade IV, 27 hips were grade III, and 4 hips were grade II. Following traction, 24 hips were grade IV, 37 hips were grade III, and 19 hips were grade II. There was a significant improvement in hip position according to IHDI classification (P < 0.001, Wilcoxon signed rank test). The outcomes in the longer-term cohort reported that only 2% of hips re-dislocated, and 94% of hips were a Severin 1 or 2 outcome (i.e. good or excellent).

Conclusions:
This study found that pre-operative Gallows traction decreases the degree of hip displacement. Despite the practicalities of the regime, this study supports its use ahead of hip open reduction surgery.

Authors:
B Sagade, C Edwards, A Aarvold, P Ross

Hospital:
University Hospital Southampton

Introduction:
The National Institute for Health and Care Excellence (NICE) has set guidelines serving as a benchmark for high quality transition services for children and young people (CYP) with chronic health conditions. We aimed to assess the services provided by the transition program running at our tertiary care hospital and to identify the unmet needs of health care in adults with neuromuscular disorders (NMDs).

Methods:
A questionnaire was designed through consensus amongst professionals and review of literature. An online survey of parents, caregivers, and patients going through NMDs was conducted to identify lacunae in transition services being provided to them.

Results:
53 families who had been transitioned were invited to participate in the study and 39 responses were received. Only 9 patients (23%) agreed that they received a transition plan for transfer of further care to an adult orthopaedic surgeon. The average score of satisfaction with the transition plan was 4/10. Care of their general health was taken over by their GP in 49% of them, while 28% patients did not have any doctor looking after them. 69% patients did not have any orthopaedic supervision whereas, 53% did not have any inputs from Spine surgeons since transitioning. 33% patients did not have continuing physiotherapy. 41% patients reported some decline and 6 (15%) reported a significant decline in their musculoskeletal health.

Conclusions:
Transition between services is challenging for families with tremendous scope for improvement. Coordination of care between Paediatric and adult services can make transition seamless for patients.

Authors:
Laura Beddard, Robert Richards

Hospital:
Queen Alexandra Hospital

Introduction:
Various factors have been proposed to influence outcome in Perthes. Choosing which patients to operate on, and when can be a challenge.
We present a prospective cohort study aiming to identify correlation between timing of surgical treatment and outcome.

Methods:
Prospective data was collected from a single centre between 28/11/1994 and 23/12/2021. Demographics, radiographic parameters, and surgical intervention were recorded on a database. Radiographic parameters recorded were Herring and Catterall grading at presentation, maximum fragmentation (Waldenstrom stage II) and Stulberg grade at skeletal maturity.

Results:
105 cases of Perthes were diagnosed in 99 patients. 66 hips have been followed up to maturity, 31 remain under review. The remaining 8 cases had incomplete data.
Children complained of symptoms at a median age of 4 years 8 months and were diagnosed on average 2 months later. The median time from the onset of symptoms to Waldenstrom stage II was 10 months.
32 hips (48%) underwent 52 open procedures. The mean time from symptoms to surgery was 18.4 months. The choice of operative intervention varied with age.
Four hips (12.5%) underwent surgery prior to reaching maximal fragmentation, 5 (16%) underwent surgery within the same month and 23 (72%) underwent surgery after this.
Stulberg grade tended to be higher in hips that underwent surgery after maximal fragmentation, although this was not statistically significant (p=0.35).

Conclusions:
Earlier surgery is likely to lead to better radiological outcomes. Understanding timing between symptoms and maximal fragmentation helps plan follow up and intervention to achieve best outcomes.

Authors:
Nic Uren, Alex Aarvold, Amanda Rhodes, S Penker, Edward Lindisfarne, Kirsten Elliot, Nicholas Clarke

Hospital:
University Hospital Southampton

Introduction:
This study reports the longer-term outcomes of the Open Reduction Capsulorrhaphy Acetabuloplasty (ORCA) procedure, utilising a minimal outer table acetabuloplasty, which aims to stimulates acetabular growth and avoid later pelvic osteotomies.

Methods:
The outcomes for 100 infants treated with ORCA, with a minimum of four year follow up, were analysed. Pre-operative patient demographics and radiological measurements were recorded. Radiological outcomes including IHDI classification, Acetabular Index (AI) and Severin grade were recorded at pre-defined post-operative intervals. The % of hips requiring further pelvic surgery was calculated. Operated hips were then compared to normal contralateral hips

Results:
The median age at the time of surgery was 15 months. Pre-operative dislocation severity was IHDI grade IV (high dislocation) in sixty cases, grade III in 28 and grade II in twelve cases. Mean pre-operative AI was 40° deg. This showed statistically significant improvements year on year (Repeated measures ANOVA, post hoc Bonferroni correction, p<0.001).
Mean AI at final follow up (range 4-12 years) was 18°, compared to 15° in the normal contralateral hips. 94% of cases have Severin Grade 1 (excellent) or 2 (good) outcome. Only 2% of patients required later pelvic osteotomy for residual acetabular dysplasia, compared to 60% of cases who do so after surgical reduction without pelvic osteotomy.

Conclusions:
This procedure, utilising a minimal acetabuloplasty, appears to be at least as effective as open reduction and any formal pelvic osteotomy. The acetabuloplasty is technically quicker to perform, is far less invasive, and is therefore a simple adjunct for the surgeons.

Authors:
Stephanie Buchan, A Bevan, Alex Aarvold, Caroline Edwards, Simon Bennet 

Hospital:
University Hospital Southampton

Introduction:
Children with a severe neuromuscular disability frequently undergo hip reconstruction surgery to prevent migration and chronic pain. These patients often have complex co-morbidities, meaning surgery carries a high risk of severe complications. It can be difficult to know when the risk outweighs the benefit. This study looked to correlate the Physiological Vulnerability Score (PVS) with outcomes of hip reconstruction surgery in children with a severe neurodisability.

Methods:
For this service evaluation, pre-operative physiological vulnerability scores were correlated against length of stay (LOS) and postoperative complications. Regression analysis was used to substratify patients undergoing femoral versus femoral and pelvic osteotomies.

Results:
There were 68 patients included, with a PVS of 0 to 21. Increased PVS had no correlation with either LOS (p=0.169) or severity of complications (p=0.981) for patients that underwent VDRO’s (n=48). However, for patients who also had a pelvic osteotomy (n=20), higher PVS was associated with increased LOS (p=0.009) and severity of complications (p=0.0002).

Conclusions:
For patients with significant medical vulnerability, the PVS was associated with a higher rate of postoperative complications and longer LOS following femoral and pelvic hip reconstruction, but not following isolated bilateral femoral osteotomies. The results support early intervention before significant acetabular changes occur. The physiological vulnerability score can be used to augment clinical decision-making and enable a more informed surgical consent by the child’s parents.

Authors:
Laura Beddard, Sophie White, Robert Richards

Hospital:
Queen Alexandra Hospital

Introduction:
Guidance from British Society for Children’s Orthopaedic Surgery (BSCOS) in April 2020 suggested that ‘clicky hips’ should not undergo routine hip ultrasound during the COVID-19 pandemic. The pathway in our unit was altered to reflect this.
We present a prospective cohort study investigating the rate of radiographic features of Developmental Dysplasia Hips (DDH) in babies with clicky hips on Newborn Infant Physical Examination (NIPE) screening.

Methods:
Prospective records of babies referred with ‘clicky hips’ and no risk factors or abnormal clinical examination findings between 01/02/2020 and 31/08/2020 were kept. Babies were invited for a pelvic radiograph aged 6 months.
Hospital records and digital radiography records of babies that were not brought to radiographic screening were reviewed to identify hip abnormalities diagnosed prior to 18 months of age.

Results:
310 babies were referred; 268 attended for pelvic radiograph aged 6 months. These radiographs were all within normal limits, no further investigation or treatment was required. 3 have been seen at a nearby centre. All 3 had ultrasound screening, one was successfully treated for DDH in a Pavlik harness.
3 presented later for clinical review due to parental concern. All hips were clinically and radiographically normal.

Conclusions:
This method of screening for DDH in babies with clicky hips is shown to be as effective as ultrasound. No babies had delayed diagnosis or treatment. One baby required treatment for DDH (0.3%), lower than the proportion found in UK studies.
This supports the continued change in practice to not routinely screen ‘clicky hips’.